Consent Form

Treatment Consent Form

All information provided on this form is strictly confidential & will become part of your child's patient record

Student Details

Child's First Name *

Child's Surname *

Street address

City

State

Postcode

Date of Birth *

Gender

MaleFemaleOther/Prefer not to answer

Name of School *

Class Group/Year Level/Teacher *

Payment Options

The following details allows our team to determine eligble payment options and provide you with an accurate invoice for your child's appointment.

An invoice for the appointment will be emailed to you based on payment options provided. Invoice is payable within 5 days of your child's completed treatment.

For our patients with HCF, CBHS, MBP, Westfund and NIB our fee schedule follow the preferred provider agreement.

We understand not all families choose to have health insurance, in which case we offer a standardised fee of $120 for a check up and clean without x-rays or $149 if x-rays are required.

My child is eligble for CDBS *

Yes No Unsure

This allows our team to check if your child is eligble for the Child Dental Benefit Scheme (CDBS). If eligble your child's appointment can be bulk billed.

Medicare Card Number (10 digits)

Child's Number On Card

Medicare Expiry Date

My child is covered by Private Health Insurance (with dental extras) *

Yes No

Please select what private health insurance your child is covered throughOur team is required to follow Health Fund charge rates, if your child is covered through a Health Fund an individualised invoice will be sent via email.

Your Details - Parent or Legal Guardian

At least one of the provided contacts must be contactable within school hours

Primary Contact

First Name *

Surname *

Relationship To Child *

Mobile Number *

Email Address *

I am available to contact in school hours

Secondary Contact

First Name *

Surname *

Relationship To Child *

Mobile Number *

Email Address *

I am available to contact in school hours

Emergency Contact Name *

Emergency Contact Mobile Number *If primary or secondary contact is uncontactable our team will contact emergency number.

I am available to contact in school hours

Medical Information

My child has an allergy (e.g latex, adhesive, penicillin, hay fever) *

Yes No

If you answered YES please specify below

Allergy

Reaction to Allergen

My child has a medical condition *

Yes No

If you answered YES please specify below

My child has a physical and/or mental disability *

Yes No

If you answered YES please describe below

My child is taking medications (inclusive of any vitamins, minerals or supplements) *

Yes No

If you answered YES please specify below

Name of Medication/Drug

Strength

Frequency Taken

Dental Information

Has your child had any dental problems in the past?

Yes No

If you answered YES please describe below

When did your child last visit a dental professional?

Less than 6 months ago More than 6 months ago Never Don't know/unsure

Where was your child's last dental visit?

Tooth Fairy & Co Another private practice Public dental clinic, van or hospital Other/unsure

Has your child had fluoride application in the last 6 months?

Yes No Don't know/unsure

Has your child had dental x-rays in the last 2 years?

Yes No Don't know/unsure

Please tick if you would like Tooth Fairy & Co to request your child's dental history and potential dental x-rays from their previous dental professional

Dental Decay Risk Assessment

To help with the assessment of your child's teeth and provide more personalised care, please tick the most appropiate box for each

How often does your child usually drink water?

Everyday A few times a week Rarely or never Don't know/unsure

How often does your child brush their teeth?

Rarely or never Once a day Twice a day or more Don't know/unsure

How often does your child eat sweet snacks? ( e.g biscuit, cake, muesli bar, protein bar, pastry, chocolate)

Everyday A few times a week Rarely or never Don't know/unsure

Is brushing assisted?

Yes, everyday Sometimes, the role is shared No, they do it on their own

How often does your child drink sugary drinks? (e.g soft drink, cordial, sport drink, energy drink, iced tea, chocolate milk)

Everyday A few times a week Rarely or never Don't know/unsure

What toothpaste does your child use?

Treatment Consent

The following consent is to be completed by child's parent/legal guardian *

I have read through and understand the information pack provided about the Tooth Fairy & Co Dental Van Program coming to my child's school.I understand that I can withdraw consent at any time. To do this contact our Tooth Fairy & Co Dental Van Coordinator Erin - 0447 131 678 I have had an opportunity to ask questions and seek clarification on any information provided by either contacting Tooth Fairy & Co or visiting our website www.toothfairyandco.com.auI understand Tooth Fairy & Co may contact me to clarify any of the information provided in this form and/or to discuss my child's oral health.I declare that I have provided accurate information about my child including any medical conditions and allergies.I understand that my child's appointment may incur a fee, a invoice will be sent dependent on selected payment option and is payable within 5 days of my child's appointment. I UNDERSTAND THE MOBILE CLINIC HAS VIDEO SURVEILLENCE FOR THE SAFETY OF MY CHILD AND A RECORD OF MY CHILD'S APPOINTMENT

Please sign each treatment that you would like your child to recieve if clinically required

Dental Check Up *